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Home My Public Portal About5018 SERENO DR_Plumbing__ WORKERS'COMPENSATION DECLARATION ,fie DPW V,D APPLICATION FOR PLUMBING PERMIT I pereby, affirm that I have a certificate of consent to self in- 76A407A sure w a certificate of Work" Compensation Insurance,or a , certified copy thereof (Sec 3800, Lab C Policy No Company ) i COUNTY OF LOS ANGELES DEPT. OF PUUIC'WORKS _ Certified copy is hereby furnished ❑ Certified co is filed with the county building in FOR APPLICANT TO FILL IN(PRIM OR TYPE) BUILDING PY N 9 spetlion NUMBER FIXTURE OR REM ADDRESS department 8 FEE LOGOl1TV 4P P r Gate Applicant WATER CLOSET(TOILET) CROSS ST OSf1 ry L` CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE SHOWER OWNER V-196 WA (This section nwd not be completed If the work imolwd by AD the permit Is for ons,hundred dollars($100)or less) LAVATORY ADDRESS 2-53 I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so i CITY 76 TEL S t as to become subject to the Workers'Compensation Laws DISHWASHER CONTRACTOR Date Applicant 1 CLOTHES WASHER ADDRESS NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING FOOL RECEPTOR emptron,you should become subject to the Workers Compen- CRY TEL NO cation provisions of the Labor Cade,You must forthwith comp- LAWN SPRINKLER SYSTEMS ly with such provisions or this permit shall be deemed revok- STATE LIC edWATER HEATER LICENSE NO CLASS LICENSED CONTRACTORS DECLARATION 1 Ops SYSTEM OUTLETS DISTRICT D� PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code and my license is in full force and ef- 5 PER SYSTEM FINALVRQUDATION fact HOSE BIB DATE Y, AS license Number Lic Class �. G ACCT. Contractor Dote - BY FINAL 0 s 284.9%r am exempt under Sec 1 ITEMS v B 8P C far this reason Plan check fee TOTAL 284 - 9 Date PLUMBING PERMIT ISSUING FEE f (� �y�A��-�-CHECK 284. Signature TOTAL FEE p ��ra'07UC .00 SINGLE FAMILY HOME OWNER BUILDER DECLARATION Plan check applicant F'Wfi��nnn I hereby affirm that I am exempt from the Contractor s License _ ss0-'LnA11 6/11/96 Law for the following reason (Section 7031 5, Business and Name Professions Code) Address 6&37 1 1019 F1 1, as owner of the property will do the work and the Ciry Tel No - A - structure is not intended or offered for sole(Section 7044, Business and Professions Code) pop.CONSTRUCTION LENDING AGENCY I hereby off irm that there is a construction lending agency for ' the performance of the work for which this permit is issued (Sec 3097, Civ C ) Lender s Name ` Lender's Address _ I certify that I hove read this apphcotion and state that the ► i above information is correct I agree to comply with all County i ordinances and State jaws regulating Plumbing, and hereby outhori a representatives this County to enter upon the above nti pro rty inspection urposes _ SEE REVERSE FOR EXPLANATORY LANGUAGE Sign ie f Permittee to COUNTY OF IAS ANGELES TEMPLE CITY # 0508 PLUMBING PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS PL 0508 1207090037 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE (626) 285-0488 EXT - LEGAL. ID FEES PAID BUILDING ADDRESS IBK 56 PG 12 PC 17 5018 SERENO DR I IFEE DESCRIPTION QUANTITY WM AMOUNT TEMP CA 91780 1 (ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET 15388-012-010 101 PERMIT ISSUANCE FEE 27 80 THOMAS PAGE 596 GRID H5 LOCALITY TEMPLE CITY, Cl (TENANT J47 WATER HEATERS) 1 00 WTH 16 20 I TOTAL FEES 99 00 ISSUED ON PROCESSED BY PIAN BY I I 107/09/12 SR I OWNER - TEL NO {�FI!J]�A/L� T FI �,/,$�Y CODE KWANO, ALLEN (626) 235-7889- l �/ I\ J 5018 SERENO DR ``" TEMPLE CITY CA 91780 I D CRIPTIOD OF WORK 1 IREMOJE/REPLACE GAS WATER RATER 46 GAL/SBEF APPLICANT TEL NO MARTINEZ NICK (323) 440-2069- 1 ISPECIAL CONDITIONS I I _ I I I I � I ICONTRACTOR TEL NO I 1APP,OVALS DATE INSPECTOR SIGNATURE I FAST WATER HEATER CO (425) 636-7059- 1 1 112601 132ND ST LIC NO 1 - 1UNDFR SLAB WORK 1 KIRKZAND WA 98034 C36931237 WATER SERVICE I PLASTIC Y/N METAL Y/N ARCHITECT OR ENGINEER TEL NO - I JROUH PLUMBING LIC NO GAS PIPING 1GAS VENT IHOT PATER HEATER I PLUMBING FIXTURES i I (LAWN SPRINKLERS I I 1 IGAS TEST I I (UTILITY COMPANY NOTIPIEDI I � � cwv I I I GRAY WATER SYSTEM I I REPORT ID DPR263 ROUTE TO BS0508